Tricuspid regurgitation
Tricuspid regurgitation increases the size of the vwave. When tricuspid regurgitation becomes severe, the combination of a prominentvwave and obliteration of the xdescent results in a single, large, positive systolic wave
Right atrial myxoma
Right atrial myxoma, or tricuspid stenosis, will slow the y descent by obstructing right ventricular filling. The y descent of the JVP is produced mainly by the tricuspid valve opening and the subsequent rapid inflow of blood into the right ventricle
Right ventricular infarction
Right ventricular infarction and constrictive pericarditis frequently result in an increase in JVP during inspiration (Kussmaul’s sign). Severe right-sided failure can also be a cause.
Right-sided heart failure
Right-sided heart failure is the most common cause of a positive abdominojugular reflux (normal JVP at rest, increases during 10 seconds of firm midabdominal compression, and only drops when pressure is released).
Complete heart block
Large awaves occur with increased resistance to filling (tricuspid stenosis, pulmonary hypertension) or when the right atrium contractsagainst a tricuspid valve closed by right ventricular systole (Cannon a waves) in complete heart block or other arrhythmias.
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. A 25-year-old woman is found to have a midsystolic murmur on routine evaluation. The murmur does not radiate but it does increase with standing. She otherwise feels well and the rest of the examination is normal.
With standing, most murmurs diminish. The two exceptions are HOCM, which becomes louder, and mitral valve prolapse, which becomes longer and louder.
A 75-year-old man is bought to the hospital because of a syncopal episode. There was no incontinence or post-event confusion. On examination, his blood pressure is 140/80 mm Hg, pulse 72/min with no postural changes. His second heart sound is diminished and there is a systolic ejection murmur that radiates to the carotids. With the Valsalva maneuver, the murmur decreases in length and intensity.
With the Valsalva maneuver, most murmurs will decrease. The exceptions are the murmurs of HOCM and mitral valve prolapse, which increase. After release of the Valsalva maneuver, right-sided murmurs tend to return to baseline more rapidly
A 22-year-old woman with no past medical history is found to have a systolic ejection murmur on routine physical examination. She has no symptoms and feels well. The murmur is heard along the right and left sternal borders and it decreases with handgrip exercises.
The murmur of HOCM often decreases with submaximal isometric exercise (handgrip). Murmurs across normal or obstructed valves will be increased. Handgrip can also accentuate an S3 or S4.
A 45-year-old woman has developed increasing SOB on exertion and fatigue. She has a loud systolic ejection murmur heard best at the left sternal border, and the murmur increases with standing. A double apical impulse is also felt.
HOCM often has a bisferiens pulse. It can also be found in pure aortic regurgitation or combined aortic regurgitation and aortic stenosis.
A 65-year-old man with a previous history of an anterior MI comes for follow-up. On examination, he has a systolic murmur heard best at the apex and radiating to the axilla. Transient external compression of both arms with blood pressure cuffs 20 mm Hg over peak systolic pressure increases the murmur.
This maneuver will increase the murmurs of mitral regurgitation, ventricular septal defect, and aortic regurgitation. Other murmurs are not affected.
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. A 56-year-old man presents with SOB, fatigue, and edema. He has also noticed weight gain, abdominal discomfort, and distension. He has a prior history of lung cancer treated with radiotherapy to the chest. There is no history of liver or cardiac disease in the past. On examination, he has an elvated JVP, prominent y descent of neck veins, and positive Kussmaul’s sign. The heart sounds are normal. The CXR shows a normal cardiac silhouette and the ECG has low voltages.
Constrictive pericarditis is characterized by a prominent y descent of the neck veins and low voltage on ECG. The presence of a positive Kussmaul’s sign helps differentiate the syndrome from cor pulmonale and restrictive cardiomyopathies
A 28-year-old woman recently developed symptoms of chest pain that changed with positioning. It was worse when lying down and relieved when sitting up. The pain is better now but she notices increasing dyspnea and edema. On examination, the blood pressure is 85/60 mm Hg with a positive pulsus paradoxus, low volume pulse at 110/min, and the heart sounds are distant. The JVP is at 7 cm with a negative Kussmaul’s sign. There are low voltages on the ECG, and a large cardiac silhouette on the CXR.
Cardiac tamponade can occur with as little as 200 mL of fluid if the accumulation is rapid. Physical examination reveals a pulsus paradoxus (>10 mm Hg inspiratory decline in systolic arterial pressure), a prominent x descent of the jugular veins, but no Kussmaul’s sign. The ECG may show low voltage
A 69-year-old woman complains of some atypical chest pain 2 days prior to presentation. On examination, the JVP is at 8 cm, positive Kussmaul’s sign, and normal heart sounds. The lungs are clear. The ECG is abnormal, and the CXR shows a normal cardiac silhouette.
RVMI is characterized by high neck veins, ECG abnormalities, and often a right-sided S3. The low cardiac output associated with RVMI can often be treated by volume expansion. Although a third of patients with inferoposterior infarctions have some degree of right ventricular necrosis, extensive RVMI is uncommon.
A 55-year-old woman with metastatic lung cancer presents with dyspnea and pedal edema. On examination, the JVP is at 10 cm, with a negative Kussmaul’s sign. The heart sounds are diminished and the lungs have bibasilar crackles. The ECG shows QRS complexes of variable height.
Electrical alternans (a beat-to-beat alternation in one or more component of the ECG signal) can occur in pericardial effusion and numerous other conditions. Total electrical alternans (P-QRS-T) and sinus tachycardia is relatively specific for pericardial effusion (often with tamponade).
A 64-year-old presents with dyspnea and edema. He had previous coronary bypass surgery 5 years ago, which was uncomplicated. Since then he has had no further chest pain. On examination, his JVP is at 8 cm, with prominent Kussmaul’s sign. The heart sounds are easily heard but there is an early diastolic filling sound (pericardial knock).
A pericardial knock is characteristic of constrictive pericarditis. It is in fact an early S3, occurring 0.06–0.12 seconds after aortic closure. S1 and S2 are frequently distant.
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A 55-year-old woman is recently diagnosed with amyloidosis. She is now noticing increasing SOB, fatigue, and edema. On examination, the JVP is at 10 cm with a negative Kussmaul’s sign but prominent x and y descent. The blood pressure is 90/70 mm Hg, no pulsus paradoxus, pulse 100/min with low volume, and normal heart sounds.
The combination of absent pulsus and absent Kussmaul’s sign with prominent x descent favors a restrictive cardiomyopathy. Unlike constrictive pericarditis, restrictive cardiomyopathies frequently present with an enlarged heart, orthopnea, LVH, and bundle branch blocks.
A 45-year-old man develops new symptoms of sudden-onset flushing involving his head and neck lasting a few minutes. He also notices watery diarrhea and abdominal pain when the flushing occurs. Serotonin and its metabolites are elevated in his urine and serum.
The cardiac lesions of gastrointestinal carcinoids are almost exclusively in the right side of the heart and occur only when there are hepatic metastases. Fibrous plaques are found on the endothelium of the cardiac chambers, valves, and great vessels. These plaques can distort cardiac valves; tricuspid regurgitation and pulmonic stenosis are the most common valvular problems.
A 25-year-old man has noticed increasing lowerback and gluteal pain. It is dull and associated with morning stiffness lasting 1 hour, and then it improves after activity. On examination, there are no active inflammatory joints but he has limited forward and lateral flexion of the lumbar spine, as well as decreased chest expansion. Xrays of his pelvis and lumbar spine show changes of sacroilitis.
The proximal aortitis of seronegative arthritis (ankylosing spondylitis, Reiter syndrome, psoriatic arthritis, or associated with inflammatory bowel disease) can result in aortic regurgitation and AV block.
A 31-year-old woman has new-onset headaches and blood pressure elevation. She also notices that the symptoms come episodically and consist of palpitations, headache, anxiety, and marked blood pressure elevation. She undergoes a workup for secondary causes of hypertension, and is found to have elevated free catecholamines in her urine.
Focal myocardial necrosis and inflammatory cell infiltration caused by high circulating levels of catecholamines are seen in about 50% of patients who die with pheochromocytoma. Hypertension can further impair left ventricular function.
A 22-year-old university student notices unintentional weight loss and palpitations for 1 month. She also complains of sweating and feeling hot all the time. On examination, her pulse is regular at 110/min, blood pressure 96/60 mm Hg; she has a diffuse enlargement of the thyroid gland. Her thyroid-stimulating hormone (TSH) is low and free T3 and T4 are elevated.
The Means-Lerman scratch, a systolic scratchy sound heard at the left second intercostal space during expiration, is thought to result from the rubbing of the hyperdynamic pericardium against the pleura. Palpitations, atrial fibrillation, hypertension, angina, and heart failure are more common cardiac manifestations of hyperthyroidism.
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A 60-year-old man presents with SOB, increasing abdominal distention, and lower leg edema. He has no prior history of cardiac, renal, or liver disease. On examination, the JVP is at 8 cm with a negative Kussmaul’s sign but prominent xand ydescent. The blood pressure is 95/75 mm Hg, no pulsus paradoxus, pulse 100/min with low volume, and normal heart sounds. There is shifting dullness of the abdomen and pedal edema. His blood glucose and hemoglobin A1C are elevated.
DM can result in a restrictive cardiomyopathy in the absence of large-vessel CAD. Histology reveals increased collagen, glycoprotein, triglycerides, and cholesterol in the myocardial interstitium. Abnormalities may be present in small intramural arteries.
A 42-year-old woman, who is an executive at a large company, is seen for her annual evaluation. She is concerned about her risk for future cardiac events since a collegue was just diagnosed with angina. She has no other medical illness and is a lifetime nonsmoker. Her fasting lipid profile is T-chol 240 mg/dL, HDL 55 mg/dL, LDL 160 mg/dL, and triglycerides 140 mg/dL.
When assessing patients for cardiovascular risk, it is always important to consider recommendations in light of their risk level. For primary prevention (no known symptomatic CAD), there are risk calculators available to estimate an individual’s future risk (see http://www.nhlbi.nih.gov/guidelines/cholesterol/for a risk calculator based on the Framingham database). The treatment recommendations and goals should match the patient’s risk level. In this individual, she has no risk factors for CAD and her 10-year risk for cardiovascular events is low. The goals for LDL in her are
A 60-year-old woman is concerned about her risk for cardiovascular disease since she is postmenopausal now. She has no symptoms of cardiac or vascular disease and her only cardiac risk factor is hypertension for the past 5 years, which is well-controlled. Her fasting T-chol is 240 mg/dL, HDL 55 mg/dL, LDL 160 mg/dL, and triglycerides 140 mg/dL.
Many observational studies have verified the increased risk of CAD in women after menopause, and this formed the basis for recommending estrogen therapy to lower cardiovascular risk in postmenopausal women. Recently two large randomized clinical trials have shown no benefit with estrogen replacement in postmenopausal women as a means of reducing cardiovascular risk. With this evidence, estrogen replacement is not recommended for cardiac risk modification, and is only indicated to treat the symptoms of menopause. For postmenopausal women at increased risk of cardiac disease, statins are considered first-line therapy in modifying risk since there are randomized trial data from multiple trials supporting their effectiveness in women. Since this patient has only one risk factor her future 10-year risk is low (<10%) and lifestyle modification is the best advice. She will require follow-up lipid risk assessment in 5 years.
A 54-year-old man with diabetes has a persistently elevated blood pressure averaging 150/90 mm Hg. He has complications of pheripheral neuropathy and a urinalysis is positive for microalbuminuria.
ACE inhibitors have no adverse effects on glucose or lipid metabolism and minimize the development of diabetic nephropathy by reducing renal vascular resistance and renal perfusion pressure. The goal for blood pressure control in diabetics is set at 130/80 mm Hg which is lower than in nondiabetics. This lower pressure is important in preventing progression of renal disease and other end-organ damage.
A 60-year-old woman with no past medical history has an elevated blood pressure of 165/80 mm Hg on routine evaluation. Repeated measurements over the next month confirm the elevated pressure. Physical examination, routine blood count, and biochemistry are all normal.
Thiazides have been a cornerstone in most trials of antihypertensive therapy. Their adverse metabolic consequences include renal potassium loss leading to hypokalemia, hyperuricemia from uric acid retention, carbohydrate intolerance, and hyperlipidemia. The current U.S. Joint National Committee (JNC-7) guidelines suggest starting with thiazide diuretics because of their proven efficacy in lowering mortality and morbidity in large clinical trials. Other agents are considered if there are comorbidities such as diabetes or CAD.
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A 26-year-old woman develops new-onset hypertension. She has no other medical problems and is not taking any medications. She undergoes an evaluation for secondary hypertension and is found to have unilateral renal artery stenosis.
Although contraindicated in bilateral stenosis, ACE inhibitors are the drug of choice in unilateral renal artery stenosis. When ACE inhibitors are used in patients with impaired renal function, renal function should be monitored twice a week for the first 3 weeks
A 70-year-old man has isolated systolic hypertension. On examination, his blood pressure is 170/80 mm Hg, heart and lungs are normal. He has no other medical conditions.
Thiazides seem to work particularly well in Blacks and the elderly. Younger individuals and Whites respond well to beta-blockers, ACE inhibitors, and calcium channel antagonists. Isolated systolic hypertension is a common occurance in the elderly. It is due to arteriosclerosis of the large arteries. Treatment of isolated systolic hypertension with low-dose thiazides results in lower stroke rates and death. The goal for treatment is a blood pressure of 140/90 mm Hg.
A 57-year-old man has a blood pressure of 155/90 mm Hg on routine evaluation. He had coronary artery bypass grafting 4 years earlier, after which he has had no further chest pain. The rest of the examination is normal, and the elevated blood pressure is confirmed on two repeat visits.
Beta-blockers are the most appropriate choice for the treatment of hypertension in patients with CAD. They lower mortality in patients with CAD as well as hypertension. ACE inhibitors can also be used, especially if there is left ventricular dysfunction, or the patient has multiple cardiovascular risk factors such as diabetes or dyslipidemia.
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